Provider Demographics
NPI:1558563379
Name:YANISH, MITZI (PTA)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:YANISH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 17TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3606
Mailing Address - Country:US
Mailing Address - Phone:701-690-8160
Mailing Address - Fax:
Practice Address - Street 1:30 7TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-456-4000
Practice Address - Fax:701-456-4805
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant